program faculty disclosures i have no relevant financial ... · 1996 when the fda approved...

Interventional Management of Acute Ischemic Stroke

Charles Anthony Bruno, Jr., D.O.

Attending Interventional Neuroradiologist

Jefferson Radiology

Hartford Hospital

Program Faculty Disclosures

I have no relevant financial relationships to disclose

I will not discuss products in my presentation

- Ischemic stroke is the leading cause of disability and fifth leading cause of

mortality in the US

- Approximately 800,000 strokes occur in the US each year - roughly one stroke

every 40 seconds

- Estimated direct and indirect cost of stroke care is over $100 billion a year

- Despite the magnitude of problem there was therapeutic nihilism for patients with

acute ischemic stroke for centuries

Background

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CCSU Sports Medicine Symposium - Tuesday March 3, 2020

- First major breakthrough in treatment of acute ischemic stroke (AIS) came in

1996 when the FDA approved intravenous tissue plasminogen activator (IV-

tPA) for use within 3 hours of symptom onset - created paradigm shift in

management of acute ischemic stroke

- Approval came following completion of a NINDS trial showing tPA improved

functional outcome at 90 days in AIS when administered within 3 hours of

symptom onset

IV-tPA

- Since the approval of IV-TPA there have been multiple randomized controlled

trials, including ECASS III, demonstrating efficacy of IV-tPA up to 4.5 hours

from symptom onset

- Limitations of IV-tPA include limited treatment window (within 4.5 hours) and

low recanalization rates for large-vessel occlusions (M1, carotid terminus,

cervical ICA)

IV-tPA

- The major drivers for the development of endovascular stroke therapy were the

desire to expand the 3-hour treatment window and the relatively low

recanalization rates for large-vessel occlusions with IV-tPA (which often caused

the most severe strokes)

- The evolution of endovascular procedures for AIS started with use of a plethora

of techniques including intra-arterial (IA) thrombolysis, mechanical manipulation

of clot with microwires and microcatheters, and percutaneous angioplasty / stents

Endovascular Therapy

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- In early 2000 physicians at UCLA developed and patented a corkscrew-like

retrieval device designed to retrieve lost endovascular coils accidentally released

into the cerebral vasculature-soon became apparent that the device could be

used for removal of endoluminal thrombi

- In 2004 the Mechanical Embolus Removal in Cerebral Ischemia (MERCI)

retriever became the first device approved for clot removal in acute ischemic

stroke - unfortunately limited recanalization rates


MERCI Retriever

Type to enter a caption.

- Second generation devices include the stentrievers, Solitaire and Trevo, and

aspiration catheters

- These newer generation devices have been shown to have significantly better,

≤90%, recanalization rates compared with the MERCI retriever


Stentrievers Clot engaged in stentriever

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Aspiration catheters and suction devices

- So… Does endovascular

therapy work?


YES!!


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- Beginning in December 2014, a series of pivotal trials were published

demonstrating that endovascular thrombectomy (EVT) was highly effective:

- MR CLEAN Investigators. A randomized trial of intraarterial treatment for acute ischemic stroke

- ESCAPE Trial Investigators. Randomized assessment of rapid endovascular treatment of ischemic stroke

- EXTEND-IA Investigators. Endovascular therapy for ischemic stroke with perfusion-imaging selection

- SWIFT PRIME Investigators. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke.

- REVASCAT Trial Investigators. Thrombectomy within 8 hours after symptom onset in ischemic stroke

- THRACE investigators. Mechanical thrombectomy after intravenous alteplase versus alteplase alone after

stroke (THRACE)

- More recent studies have shown safety and benefit of mechanical thrombectomy

up to 24 hours after symptom onset - DAWN / DEFUSE trials


Non-contrast head CT

Right CCA

Early ischemic change

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Type to enter a caption. Type to enter a caption.

Basilar artery

Thank You

Questions?

References

1. Jayaraman MV, Hussain MS, Abruzzo T, et al. Embolectomy for stroke with emergent large vessel

occlusion (ELVO): report of the Standards and Guidelines Committee of the Society of

NeuroInterventional Surgery. J Neurointerv Surg 2015;7:316–21.doi:10.1136/neurintsurg-2015-

011717

2. Gandhi CD, Al Mufti F, Singh IP, et al. Neuroendovascular management of emergent large vessel

occlusion: update on the technical aspects and standards of practice by the Standards and Guidelines

Committee of the Society of NeuroInterventional Surgery. J Neurointerv Surg 2018;10:315–

20.doi:10.1136/neurintsurg-2017-013554

3. Pride GL, Fraser JF, Gupta R, et al. Prehospital care delivery and triage of stroke with emergent large

vessel occlusion (ELVO): report of the Standards and Guidelines Committee of the Society of

Neurointerventional Surgery. J Neurointerv Surg 2017;9:802–12.doi:10.1136/neurintsurg-2016-012699

4. Mokin M, Pendurthi A, Ljubimov V, et al. ASPECTS large vessel occlusion, and time of symptom

onset: estimation of eligibility for endovascular therapy. Neurosurgery 2018;83:122–7

5. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute

ischemic stroke. N Engl J Med 2015;372:11–20.doi:10.1056/NEJMoa1411587

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http://dx.doi.org/10.1136/neurintsurg-2015-011717



http://dx.doi.org/10.1056/NEJMoa1411587

program faculty disclosures i have no relevant financial ... · 1996 when the fda approved...

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